Wellbridge Of Fenton
Inspection history, citations, penalties and survey trends for this long-term care facility in Fenton, Michigan.
- Location
- 901 Pine Creek Drive, Fenton, Michigan 48430
- CMS Provider Number
- 235715
- Inspections on file
- 29
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Wellbridge Of Fenton during CMS and state inspections, most recent first.
Two residents were involved in a physical altercation near the café line, after which a nurse separated them and documented new, bleeding facial abrasions for both, cleaned with normal saline and left open to air, with notation that the physician was notified. One resident, with Alzheimer’s dementia and multiple comorbidities but intact cognition, had a documented facial abrasion, yet the subsequent physician note only listed an altercation as the chief complaint and did not describe the facial injury or a related physical exam, and the behavior care plan referenced the altercation without noting injury. The other resident, with autism, mild intellectual disability, epilepsy, mood disorder, and cardiovascular comorbidities, had a larger cheek abrasion documented by nursing, but the physician note likewise only referenced an altercation without a skin assessment or mention of being hit in the face; a later provider note documented normal skin findings. Surveyors found there was no timely physician assessment or documentation of the facial wounds for either resident following the incident, despite facility policy requiring physician supervision of medical care and participation in assessment and monitoring of changes in status.
The facility failed to ensure timely response to call lights, affecting several residents' dignity and care. A resident with multiple health issues couldn't reach their call light, while others reported long delays in response, leading to accidents. One resident was left in the bathroom for 16 minutes without assistance, and staff were observed not responding promptly to requests for help.
A facility's medication error rate reached 20.69% due to improper administration practices. An LPN failed to prime an insulin pen and administered insulin after a resident ate. Another resident received a Lidocaine patch with Menthol instead of plain Lidocaine, and was not instructed to rinse after using Symbicort. An RN administered multiple eye drops without waiting between doses or instructing the resident to close their eyes, violating facility policy.
The facility failed to properly label, store, and dispose of medications, leading to unsecured controlled substances, reused syringes, and expired or undated medications in storage rooms. Additionally, a resident's room contained unsecured iodine, which the resident was unaware of. Staff acknowledged improper practices despite previous training, and no policy on medication storage was provided.
The facility failed to update and individualize care plans for two residents, leading to safety risks and unmet needs. A resident with a history of falls was unsupervised outside, resulting in a hip fracture. Another resident developed a skin impairment that was not documented or addressed in the care plan. The deficiencies highlight a lack of documentation and communication among staff.
A resident with multiple health issues developed a significant skin excoriation due to limited movement from a small bed. Despite an assessment by multiple staff, there was no documentation or updated care plan for the skin impairment. Miscommunication among staff led to a lack of documentation, and the facility failed to provide the requested skin care policy.
A resident with a history of falls and dementia was observed being pushed in a wheelchair without footrests by a CNA, leading to potential injury risks. The CNA acknowledged the lack of footrests and expressed surprise at the facility's practices compared to previous workplaces. The facility lacked a specific policy on wheelchair footrest use, and no care plan addressed this aspect for the resident.
A facility failed to have a physician's order and proper documentation for catheter changes for a resident with kidney failure and other conditions. The resident recalled a recent catheter change due to leakage, but there was no documentation in the EMR. A nurse confirmed the need for an as-needed order and documentation, aligning with the facility's catheter care policy.
A facility failed to provide timely dialysis care and documentation for a resident with acute kidney failure and chronic kidney disease. The facility did not enter a physician's order to monitor the dialysis perma-cath site until after the resident had already received dialysis twice. Additionally, the required Wellbridge Dialysis Assessment form was incomplete for one session and missing for another, as confirmed by the Infection Control Nurse.
The facility failed to maintain sanitary conditions and proper maintenance of kitchen equipment, affecting 81 residents. Observations included a calcium-like build-up on the ice machine door gasket, improperly cleaned knives and silverware, and a leaking dishwasher causing standing water. The Infection Control Nurse was not adequately trained for kitchen inspections, and there was no documentation of equipment checks.
The facility failed to ensure proper hand hygiene during medication administration for two residents. An RN did not perform hand hygiene before entering residents' rooms or before preparing and administering medications. A Clinical RN confirmed that hand hygiene should be performed, as per the facility's policy.
The facility failed to ensure residents' dignity and timely care by not keeping call lights within reach or responding promptly, leading to unmet needs and frustration. Reports of staff disrespect and abuse were noted, with one resident feeling unsafe. Additionally, poor communication with resident representatives led to a medication error, contributing to a resident's death.
A resident on anticoagulant therapy experienced two falls, with the second fall leading to a decline in mental status. The facility failed to promptly inform the physician of the resident's condition, resulting in a delay in treatment and hospitalization for a brain bleed. The nurse manager noticed changes in the resident's condition but did not communicate them effectively, and the nurse practitioner did not evaluate the resident in person. The family insisted on hospital evaluation, where the brain bleed was diagnosed.
A resident with severe cognitive impairment developed in-house pressure ulcers on both elbows. The facility delayed entering physician orders for wound care and updating the care plan. Nursing staff identified the wounds but did not promptly update the care plan or enter orders, contrary to facility policy.
The facility failed to store nebulizer equipment properly and follow physician's orders for oxygen administration for two residents. A resident with chronic respiratory failure had a nebulizer with liquid left in the chamber and was receiving oxygen at an incorrect rate. Another resident with severe cognitive impairment had a nebulizer mask with fluid left on an overbed table. Facility policies for nebulizer equipment and oxygen administration were not adhered to.
A facility failed to obtain timely physician visit documentation for a resident, leading to delayed treatment orders. The resident, with Atrial Fibrillation and other conditions, experienced a gap in physician visits exceeding 60 days, against policy. The NP did not examine the resident post-fall, as symptoms were considered baseline. The resident later had a brain bleed diagnosis after a fall.
A nurse failed to follow Enhanced Barrier Precautions (EBP) by not wearing the required PPE during wound care for a resident with severe cognitive impairment and multiple medical conditions. Despite a physician's order for EBP, the nurse and a hospice caregiver did not use gowns and gloves, as mandated for high-contact care activities. The infection control nurse confirmed the expectation for staff to adhere to EBP guidelines.
Two residents experienced falls without adequate post-fall monitoring or meaningful interventions. One resident fell during a hospice respite stay without documented neurological checks, while another resident had three consecutive falls with injuries due to inadequate toileting and ineffective interventions. The facility failed to follow its fall reduction policy, resulting in missing documentation and inconsistent monitoring.
The facility failed to ensure communication between clinical services and social services to develop a person-centered care plan for a resident with schizophrenia and other medical conditions, resulting in unmet care needs and emotional distress. The resident exhibited significant behavioral issues, and the facility's response was inadequate, leading to an incident where the resident was found alone in a dark bathroom, covered in feces, and emotionally distressed.
Lack of Timely Physician Assessment After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely physician assessments and documentation for two residents following a resident-to-resident physical altercation that resulted in facial injuries. On the morning of 10/18/2025, two residents engaged in an altercation near the facility café while in line, during which one resident struck the other in the face. A nurse (Nurse W) encountered the residents immediately afterward, separated them, and assessed both for injuries. Nursing documentation for both residents on 10/18/2025 described new in-house acquired facial abrasions that were bleeding, which were cleaned with normal saline and left open to air, and indicated that the physician (Physician U) was notified. For the first resident, who had diagnoses including Alzheimer’s dementia, diabetes, depression, kidney failure, hypertension, gout, GERD, and a history of falls, the MDS showed intact cognition with a BIMS score of 15/15 and a need for some assistance with care. Nursing notes documented scratches to the nose and face, and a Skin & Wound Evaluation recorded a new facial abrasion measuring 0.6 cm by 0.4 cm that was bleeding. Although the wound note indicated the physician was notified, the subsequent physician visit note dated 10/20/2025 listed the chief complaint as “altercation with a resident” but did not mention that the resident had been hit in the face, did not describe the facial wound, and did not document a physical assessment of the injury. The resident’s behavior care plan referenced involvement in a resident-to-resident physical altercation but did not mention that the resident was injured. For the second resident, who had diagnoses including autism, mild intellectual disabilities, epilepsy, mood disorder, restlessness and agitation, heart disease, history of stroke, peripheral vascular disease, gout, and hypothyroidism, a prior care transition note indicated moderately impaired cognition with a BIMS score of 12/15. Nursing documentation on 10/18/2025 described scratches to the left side of the face, and a Skin & Wound Evaluation recorded a new in-house acquired abrasion on the left cheek measuring 3.3 cm by 1.6 cm that was bleeding and had been cleaned, with notation that the physician was notified. A physician visit note dated 10/20/2025 listed the chief complaint as “altercation with other resident” but did not mention a skin assessment or that the resident had been hit in the face. A later provider note on 10/30/2025 documented a skin inspection with “no rash or lesions,” but there was no earlier physician assessment of the facial injury. Surveyors determined there was no physician or provider assessment of either resident’s injuries from the 10/18/2025 altercation until 10/30/2025, and the facility’s policy stated that each resident’s medical care is under the supervision of a licensed physician who participates in assessment and care planning and monitors changes in medical status.
Failure to Ensure Timely Response to Call Lights
Penalty
Summary
The facility failed to ensure the dignity of several residents by not having call lights within reach and not responding to them in a timely manner. Resident #73, who has multiple health issues including memory deficits and confusion, was observed unable to reach his call light, which was hanging over the breathing machine's tubing. During a confidential Resident Council group meeting, several residents complained about the excessive time staff took to answer call lights, with one resident stating they soiled themselves due to the delay. Another resident mentioned that staff were talking on their phones in their room, and some residents reported having accidents because of the delayed response to call lights. Additionally, Resident #66 was left in the bathroom for 16 minutes without assistance, despite requiring substantial help due to severe cognitive impairment and physical limitations. A visitor had to assist the resident and loudly requested staff assistance, but the staff present did not respond until prompted by a Unit Manager. Resident #68 reported that although their call light was within reach, staff were slow to respond when it was used. Resident #281 also stated that while their call light was always in reach, the response time varied significantly, sometimes taking up to 12 hours. These incidents highlight the facility's failure to adhere to its dignity and call light policies, which emphasize prompt response to residents' needs.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 20.69% error rate during the survey. This was observed in the administration of medications to three residents. For Resident #34, a Licensed Practical Nurse (LPN) did not prime the insulin pen before administration and held the pen in place for only four seconds instead of the required ten seconds. Additionally, the resident's blood glucose was checked and insulin was administered after the resident had already eaten breakfast, contrary to the prescribed procedure. For Resident #288, the LPN applied a Lidocaine patch with Menthol, which was not in accordance with the resident's order for a plain Lidocaine patch. The previous patch was not removed as scheduled, and the new patch was applied without proper adherence. Furthermore, the LPN failed to instruct the resident to rinse and spit after administering Symbicort, as required by the medication administration protocol. Resident #28 received three different eye drop medications in quick succession without the required waiting period between administrations. The Registered Nurse (RN) did not apply pressure to the tear duct or instruct the resident to close their eyes after administering the eye drops, which is against the facility's policy. These actions and inactions contributed to the high medication error rate observed during the survey.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, storage, and disposal of medications and medical supplies in accordance with professional standards. During an observation and interview, it was found that controlled substances were not stored securely, as evidenced by used oral medication syringes being left in the narcotic cabinet. The Registered Nurse (RN) admitted that these syringes were reused for a hospice resident receiving liquid morphine, despite having an adequate supply of new syringes. This practice raised concerns about infection control, especially since multiple resident medications were stored in the same cabinet. Further inspection of the medication storage rooms revealed several issues, including open and undated vials of medications, expired saline solutions, and visibly soiled containers. The Unit Manager acknowledged that over-the-counter medications were not dated when opened and were improperly stored in the medication room instead of in-room cabinets. Despite previous training to prevent such practices, open medications were found in the medication room, and there was no documentation of medications removed from hallway cabinets, which were reportedly shut down a year ago. Additionally, a resident's room was found to have a bottle of iodine left unsecured on the dresser. The resident, who has severe cognitive impairment, was unaware of the iodine's presence. The Licensed Practical Nurse (LPN) confirmed that the iodine should have been secured in a medicine cabinet and speculated that it was left out by the night nurse after wound care. The facility failed to provide a policy or procedure related to medication storage when requested by the surveyors.
Failure to Update and Individualize Care Plans for Residents
Penalty
Summary
The facility failed to update and individualize care plans for two residents, leading to potential safety risks and unmet needs. Resident #28, who has a history of falls and multiple medical conditions including vascular dementia and poor mobility, was not supervised while outside the facility. Despite being at high risk for falls, the resident's care plan did not include interventions for supervision during outdoor activities. This oversight resulted in the resident tipping over her wheelchair outside, leading to a hip fracture and hospitalization. Resident #55, who has chronic health issues and requires substantial assistance with daily activities, developed a new skin impairment that was not documented or addressed in the care plan. During a wound care observation, a large excoriation was found on the resident's lower back, but there was no documentation of the assessment, treatment, or care plan update for this condition. The nursing staff assumed that documentation would be completed by others, resulting in a lack of recorded care for the skin impairment. The deficiencies highlight a failure in the facility's processes for updating and individualizing care plans based on residents' changing needs and conditions. The lack of documentation and communication among staff contributed to the oversight in care planning, potentially compromising the residents' safety and well-being.
Failure to Document and Address Skin Care Needs
Penalty
Summary
The facility failed to ensure comprehensive skin care for a resident, resulting in a deficiency related to skin and wound care. The resident, who was admitted with multiple diagnoses including Chronic Diastolic Congested Heart Failure and Severe Morbid Obesity, complained of pain and discomfort due to a small bed that limited her movement. This limitation contributed to the development of a sore on her back. During a wound care observation, it was found that the resident had developed a 14-inch excoriation across her lower back, described as Moisture-Associated Skin Damage (MASD). Despite the presence of multiple staff members during the assessment, there was no documentation of the skin impairment, treatment, or updated care plan in the resident's clinical record. The deficiency was further compounded by a lack of communication and documentation among the staff. The nurse manager assumed that the nurse who performed the assessment would document the findings, while the corporate clinical staff believed the nurse manager would handle the documentation. As a result, there was no record of the skin assessment or treatment in the resident's notes, and no physician order was documented for the newly observed skin impairment. Additionally, the facility did not provide the requested policy for Skin Care and Wound Management, highlighting a gap in procedural adherence.
Failure to Implement Wheelchair Safety Procedures
Penalty
Summary
The facility failed to implement policies and procedures to mitigate the risk of injury during wheelchair transport for a resident. On a specific date, a resident was observed being pushed down the hallway in a wheelchair without footrests by a CNA. The resident was attempting to hold their legs up, and their feet were observed getting closer to the floor as they were pushed. The CNA confirmed that they were pushing the resident without footrests and acknowledged that most residents did not have footrests available for their wheelchairs. The CNA expressed surprise at the lack of footrest availability, as it was a requirement for resident safety at other facilities they had worked at. The resident involved had a history of dementia, chronic kidney disease, hallucinations, and repeated falls, with a care plan addressing their risk for falls. However, there was no care plan in place regarding footrest use while being pushed in a wheelchair. The facility's RN revealed that the need for footrests was based on individual residents, and there was no policy or procedure related to wheelchair mobility and foot pedal use. A policy or procedure pertaining to wheelchair transport was requested from the facility Administrator but was not provided by the conclusion of the survey.
Lack of Physician's Order and Documentation for Catheter Changes
Penalty
Summary
The facility failed to ensure that a physician's order was in place for indwelling catheter changes and that these changes were documented for a resident. The resident, who is of advanced age, was admitted with diagnoses including kidney failure, depression, hypertension, and surgical aftercare following genitourinary surgery. During a record review, it was found that while there was a care plan for catheter use, there was no order specifying intervals for changing the catheter. The resident recalled a recent catheter change due to leakage, but there was no documentation in the electronic medical record to confirm this change. An interview with a registered nurse revealed that there should be at least an as-needed order for catheter changes and documentation when a catheter is changed. The facility's policy on catheter care, revised in October 2010, suggests changing catheters based on clinical indications rather than fixed intervals and requires detailed documentation of catheter care. However, in this case, the absence of a physician's order and lack of documentation for catheter changes were identified as deficiencies.
Failure to Provide Timely Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide timely and appropriate dialysis care for a resident who required such services. The resident, who is cognitively intact, was admitted with diagnoses including acute kidney failure, chronic kidney disease, congestive heart failure, and dependence on renal dialysis. Despite attending dialysis sessions, the facility did not enter a physician's order to monitor the dialysis perma-cath site until after the resident had already received dialysis on two occasions. This delay resulted in the absence of necessary monitoring of the dialysis perma-cath site. Additionally, the facility did not follow a physician's order to complete the Wellbridge Dialysis Assessment form. The form was incomplete for one dialysis session and entirely missing for another. The Infection Control Nurse confirmed that the forms should have been completed and acknowledged the oversight in entering the physician's order for monitoring the dialysis perma-cath site. The facility's policy on the care of residents with end-stage renal disease outlines the importance of staff education and training, including the need for timely and accurate documentation and monitoring.
Sanitation and Equipment Maintenance Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain food preparation and kitchen equipment in a sanitary and good working condition, as well as ensure proper maintenance of kitchen equipment, specifically the dishwasher. During an inspection, it was observed that the inside door of the ice machine had a build-up of a calcium-like hard white substance on the door gasket, which was directly over the ice. Although the facility had identified this issue and ordered new gaskets, the problem persisted. Additionally, clean knives and silverware were found with dried food particles, and clean pans were stacked with water and food particles inside them, indicating improper cleaning and drying practices. Furthermore, there was an excessive amount of standing water on the floor in front of the dishwasher, which was found to be leaking from the drain trap. The facility's Infection Control Nurse, who was new to the role, had not been shown how to conduct a kitchen infection control tour, and there was no documentation of inspections for the dishwasher or ice machine in the facility's Interdepartmental Infection Control Rounds sheets. These deficiencies affected 81 residents who consumed oral nutrition from the facility kitchen.
Failure to Implement Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to implement proper hand hygiene practices during medication administration, as observed with two residents. During a medication pass observation, a Registered Nurse (RN) did not perform hand hygiene before entering the room of the first resident or before preparing and administering medications. Similarly, the RN did not perform hand hygiene before entering the room of the second resident or before obtaining and administering medications. An interview with a Clinical RN confirmed that staff should perform hand hygiene before and after medication administration. The facility's policy on medication administration, dated 9/1/23, requires handwashing and sanitization before beginning a medication pass, prior to handling medication, and after direct contact with a resident.
Deficiencies in Resident Care and Communication
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, particularly in relation to the accessibility and timely response to call lights, as well as the involvement of resident representatives in care planning. Several residents reported issues with call lights not being within reach or not being answered promptly, leading to unmet care needs and feelings of frustration. For instance, one resident was unable to reach their call light and reported waiting over 30 minutes for assistance, while another resident resorted to yelling for help due to delayed responses. Additionally, there were reports of poor attitudes and disrespectful behavior from staff members. One resident described aides as having bad attitudes and not being nice, while another resident reported a CNA being verbally and physically abusive. This included an incident where a CNA yelled at a resident for taking too long to get to the bathroom and physically grabbed the resident's gown. The resident expressed feeling unsafe and uncomfortable in the facility. The facility also failed to adequately involve resident representatives in care planning and communication. A resident's family member reported difficulties in obtaining a list of medications and participating in a care conference due to technical issues. This lack of communication contributed to a situation where a resident was administered a medication that had previously caused severe health issues, ultimately leading to the resident's death. The facility's policies on resident rights and call light response were not adhered to, resulting in significant deficiencies in the care provided.
Failure to Monitor and Report Post-Fall Decline
Penalty
Summary
The facility failed to promptly monitor and inform the physician regarding the declining status of a resident following a fall, which resulted in a delay in treatment and hospitalization. The resident, who was on anticoagulant therapy due to a history of atrial fibrillation, experienced two falls within a short period. After the second fall, the resident's mental status began to decline, showing signs of lethargy and sluggishness, which were not immediately communicated to the physician. The nurse manager, who was not present during the falls, assessed the resident later in the day and noticed a change in the resident's condition. Despite these observations, the nurse practitioner was only informed of the fall and ordered COVID-19 testing and precautions without evaluating the resident in person. The resident's family, noticing the decline, insisted on hospital evaluation, where a brain bleed was diagnosed. The facility's fall policy required monitoring for delayed consequences of falls, including neurological assessments, which were not adequately followed. The lack of timely communication and assessment contributed to the delay in recognizing the severity of the resident's condition, ultimately leading to hospitalization for a brain bleed.
Delayed Wound Care Orders and Care Plan Updates for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to timely enter a physician's order for wound care and update a skin integrity care plan for a resident with pressure ulcers. The resident, who is severely cognitively impaired and unable to communicate effectively, was admitted with conditions including cerebral infarction, contractures, and dementia. During the survey, the resident was observed with dressings on both elbows, which were propped on pillows for pressure reduction. The resident developed a Stage 3 pressure ulcer on the left elbow and a Stage 2 ulcer on the right elbow, both acquired in-house. However, orders for wound care were not placed until four days after the ulcers were identified, and the care plan was updated six days after the development of the ulcers. Interviews with nursing staff revealed a breakdown in the process of wound identification and care plan updates. An LPN stated that orders should be entered as soon as a wound is identified, ideally the same day. However, the RN who identified the wounds did not enter an order into the electronic medical record, instead applying a foam dressing and notifying the next shift and management. The RN expressed discomfort with updating care plans, which contributed to the delay. The facility's policies require timely physician orders for wound treatment and prompt care plan revisions when a resident's condition changes, but these protocols were not followed in this instance.
Improper Storage of Nebulizer Equipment and Oxygen Administration
Penalty
Summary
The facility failed to properly store nebulizer equipment and follow physician's orders for oxygen administration for two residents. Resident #3, who has diagnoses including congestive heart failure and chronic respiratory failure, was observed with a nebulizer machine on the nightstand containing liquid in the medication chamber, which was not in accordance with the facility's policy for nebulizer equipment storage. Additionally, Resident #3 was receiving oxygen at 3 liters per minute, contrary to the physician's order for continuous oxygen at 2 liters per minute. The LPN on duty was unaware of why there was fluid in the nebulizer chamber and later adjusted the oxygen flow to the correct rate after verification. Resident #10, who has severe cognitive impairment and diagnoses including pneumonia and Alzheimer's disease, was found to have a nebulizer mask setup with fluid in the medication chamber on an overbed table. The nebulizer had last been signed out at 8:00 AM, but the equipment was not stored properly as per the facility's policy. An LPN acknowledged the issue and disposed of the nebulizer. The facility's policies for nebulizer equipment and oxygen administration were not followed, leading to these deficiencies.
Failure to Obtain Timely Physician Visit Documentation
Penalty
Summary
The facility failed to obtain timely physician visit documentation for a resident, resulting in delayed implementation of treatment orders and the potential for inappropriate physician's orders. The resident, who was admitted with diagnoses including Atrial Fibrillation and Chronic Respiratory Failure, experienced a gap in physician visits exceeding 60 days, contrary to the facility's policy requiring visits at least once every 60 days after the first 90 days of admission. This gap was identified during a review of the resident's electronic medical records, which showed that the resident was seen by a practitioner on several dates, but there was a significant gap between two specific dates. The Nurse Practitioner (NP) involved in the resident's care acknowledged the gap in visits and explained the protocol of alternating visits with the physician. The NP recalled being informed of the resident's fall but did not examine the resident post-fall, as the symptoms reported were considered baseline. The resident, who was on anticoagulant therapy, fell twice and was later diagnosed with a brain bleed after being sent to the emergency room. The NP did not recommend sending the resident to the hospital initially, as no abnormal neurological symptoms were reported at the time. The facility's Physician Visit Policy was reviewed, revealing the requirement for regular physician visits, which was not adhered to in this case.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to its policy for Enhanced Barrier Precautions (EBP) during wound care for a resident, resulting in a deficiency. The resident, who is severely cognitively impaired and unable to communicate effectively, was admitted with conditions including cerebral infarction, contractures, dementia, and age-related physical debility. A physician's order dated September 5, 2024, required the use of gowns and gloves for high-contact care activities, including wound care, due to the resident's conditions such as a foley catheter, peg tube, and pressure wound. On October 24, 2024, a nurse performed wound care on the resident without wearing the required personal protective equipment (PPE) for EBP. The nurse, along with a hospice caregiver, conducted the wound care procedure without donning gowns and gloves, which are mandated for high-contact care activities. Upon completion, the nurse acknowledged the oversight when informed of the EBP requirement. The infection control nurse confirmed that staff are expected to follow EBP guidelines, which include wearing gowns and gloves for high-contact activities, and stated that monthly education is provided to staff on these protocols.
Inadequate Post-Fall Monitoring and Documentation
Penalty
Summary
The facility failed to adequately document and monitor post-fall incidents for two residents, leading to deficiencies in care. Resident #701, who was on a hospice respite stay, experienced a fall without any subsequent post-fall monitoring or neurological checks documented. The resident had severe cognitive impairment and required assistance with activities of daily living. Despite the fall being reported, there was no documentation of any injuries or follow-up care before the resident was discharged home. Resident #703 experienced three consecutive falls while attempting to go to the bathroom, resulting in injuries including a scalp bruise and a goose egg on the forehead. The facility did not implement meaningful interventions to prevent further falls, and there was a lack of consistent neurological checks and monitoring of injuries. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was not toileted appropriately, which contributed to the falls. The facility's interventions, such as clipping the call light to the blanket and ensuring adequate lighting, were not effective in preventing further incidents. Interviews with the Director of Nursing and Unit Manager revealed that the facility's response to the falls was inadequate, with missing documentation and inconsistent neurological checks. The facility's policy on fall reduction was not followed, as there was a lack of physical assessment and documentation after the falls. The staff acknowledged the deficiencies in monitoring and documentation, indicating an understanding of the concerns raised.
Failure to Provide Person-Centered Behavioral Health Care
Penalty
Summary
The facility failed to ensure communication between clinical services and social services to develop a person-centered care plan for Resident #501, resulting in unmet care needs and a lack of individualized approaches to care. Resident #501, who had a history of brain bleed, schizophrenia, visual loss, and other medical conditions, was admitted to the facility and exhibited significant behavioral issues, including combativeness and refusal of care. Despite these behaviors, the facility did not develop specific resident-centered interventions and relied on generic care plans that did not address the resident's unique needs and preferences. The progress notes revealed that Resident #501 repeatedly refused care, was combative, and had episodes where she was found with feces on her body. The staff's approach to managing her behavior was inconsistent, with some staff members being able to provide care while others were not. The facility's response to her behavioral issues was inadequate, as they were waiting for a psychiatric evaluation that had not yet occurred. The resident's care plan lacked specific interventions to address her schizophrenia and behavioral symptoms, and there was no documented order for a behavioral health referral. On one occasion, EMS staff found Resident #501 alone in a dark bathroom, covered in feces, and emotionally distressed. The EMS report indicated that the resident was alert and oriented but was left in unsanitary conditions without proper supervision. The facility staff did not provide an adequate explanation for why the resident was left in such a state, and the EMS staff had to clean her up before transferring her to the hospital. This incident highlights the facility's failure to provide necessary behavioral health care and services, resulting in unmet care needs and emotional distress for the resident.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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